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5           2022 Form OR-19                                                                                                                                 Office use only      5
6           Page 1 of 2, 150-101-182               Oregon Department of Revenue                                15772201010000                                                    6
7           (Rev. 08-09-22, ver. 01)                                                                                                                                             7
8           Annual Report of Pass-through Entity Owner Tax Payments                                                                                                              8
9                                                                                                                                                                                9
10                                                                                                                                                                               10
11                                                                  Submit original form—do not submit photocopy.                                                                11
12          Pass-through entity (PTE) name                                                                  Federal employer identification number (FEIN)                        12
13          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                                             99-9999999–                                                          13
14          PTE address                                                                                City                                   State       ZIP code               14
15                                                                                                                                                                               15
16          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXContact first name (see instructions) Initial Last name XXXXXXXXXXXXXXXXXXXXXContact phone XX              XXXXX-XXXX             16

17          XXXXXXXXXXXX                   X                   XXXXXXXXXXXXXXXXXXXX                                       999-999-9999– –                                        17
18          Section 1                                                                                                                                                            18
19                                                                                                                                                                               19
20          Type of entity: X        Partnership               X S corporation                         X LLC   X          LLP    X LP         X           Trust                  20
21                                                                                                                                                                               21
22                                                                                                                                                                               22
23                                                                                                                                                                               23
24                                         Estimated payments               Payment amount                                       Payment date                                    24
25                                                                                                                               (MM/DD/YYYY)                                    25
26                                                                                                                                                                               26
27                                                             Payment 1 99,999,999,999.00.00                             99/99/9999/ /                                          27
28                                                                                                                                                                               28
29                                                                                                                                                                               29
30                                                             Payment 2 99,999,999,999.00.00                             99/99/9999/ /                                          30
31                                                                                                                                                                               31
32                                                                                                                                                                               32
33                                                             Payment 3 99,999,999,999.00.00                             99/99/9999/ /                                          33
34                                                                                                                                                                               34
35                                                                                                                                                                               35
36                                                             Payment 4 99,999,999,999.00.00                             99/99/9999/ /                                          36
37                                                                                                                                                                               37
38                                         Important—Complete page 2 before signing and mailing form.                                                                            38
39                                                                                                                                                                               39
40                                                                                                                                                                               40
41                                                                                                                                                                               41
42          Sign below and keep a copy of this return for your tax records.                                                                                                      42
43          Under penalties for false swearing, I certify that I am authorized to request transfer of estimated tax payments from the above-                                     43
44          named pass-through entity’s tax account to the tax accounts listed on this form.                                                                                     44
45                                                                                                                                                                               45
46          General partner, LLC member, or officer signature                                            Title                                                                   46

47          X                                                                                            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                     47
48          General partner, LLC member, or officer first name      Initial Last name                                                     Date                                   48
49          XXXXXXXXXXXX                                            X       XXXXXXXXXXXXXXXXXXXX                                          99/99/9999/     /                      49
50          Paid preparer first name                                Initial Last name                                                     Date                                   50
51          XXXXXXXXXXXX                                            X       XXXXXXXXXXXXXXXXXXXX                                          99/99/9999/     /                      51
52          Paid preparer signature                                                                      Preparer address                                                        52

53          X                                                                                            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                     53
54                                                                                                       City                                  State        ZIP code             54
55          You can mail Form OR-19 to:                                                                  XXXXXXXXXXXXXXXXXXXXX XX                           XXXXX-XXXX           55
56          Oregon Department of Revenue                                                                 Preparer license number               Phone                             56
57          PO Box 14950                                                                                                                       999-999-9999–    –                57
                                                                                                         XXXXXXXXXX
58          Salem OR 97309-0950                                                                                                                                                  58
59                                                                                                                                                                               59
60                                   This form is due on the last day of the second month after the end of the entity’s tax year.                                                60
61                                         The due date for entities using a calendar 2022 tax year is February 28, 2023.                                                        61
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5           2022 Form OR-19                                                                                                                          5
6           Page 2 of 2, 150-101-182         Oregon Department of Revenue     15772201020000                                                         6
7           (Rev. 08-09-22, ver. 01)                                                                                                                 7
8           Section 2 —Submit additional copies of this page when reporting for more than four owners                                                8
9           (1) Owner first name     Initial Last name                    Social Security number (SSN) Owner type (see instructions)                 9
10                                   X                                    999-99-9999– –               XXXXXXXXXXXXX                                 10
11          XXXXXXXXXXXXEntity name          XXXXXXXXXXXXXXXXXXXX                 FEIN                                                               11

12          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                   99-9999999–                                                        12
13          Address                                                 City                               State   ZIP code                              13
14                                                                                                                                                   14
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                     XXXXXXXXXXXXXXXXXXXXX              XX      XXXXX-XXXX
15                  (a) Payment 1                (b) Payment 2                (c) Payment 3                (d) Payment 4                             15
16                                                                                                                                                   16
            99,999,999,999.00.00             99,999,999,999.00.00         99,999,999,999.00.00         99,999,999,999.00.00
17                                                                                                                                                   17
18                                                                                                         Total for owner                           18
19                                                                                                                                                   19
                                                                                                       99,999,999,999.00.00
20                                                                                                                                                   20
21          (2) Owner first name     Initial Last name                    SSN                          Owner type (see instructions)                 21
22                                   X                                    999-99-9999– –               XXXXXXXXXXXXX                                 22
23          XXXXXXXXXXXXEntity name          XXXXXXXXXXXXXXXXXXXX                 FEIN                                                               23

24          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                   99-9999999–                                                        24
25          Address                                                 City                               State   ZIP code                              25
26                                                                                                                                                   26
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                     XXXXXXXXXXXXXXXXXXXXX              XX      XXXXX-XXXX
27                  (a) Payment 1                (b) Payment 2                (c) Payment 3                (d) Payment 4                             27
28                                                                                                                                                   28
            99,999,999,999.00.00             99,999,999,999.00.00         99,999,999,999.00.00         99,999,999,999.00.00
29                                                                                                                                                   29
30                                                                                                         Total for owner                           30
31                                                                                                                                                   31
                                                                                                       99,999,999,999.00.00
32                                                                                                                                                   32
33          (3) Owner first name     Initial Last name                    SSN                          Owner type (see instructions)                 33
34                                   X                                    999-99-9999– –               XXXXXXXXXXXXX                                 34
35          XXXXXXXXXXXXEntity name          XXXXXXXXXXXXXXXXXXXX                 FEIN                                                               35

36          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                   99-9999999–                                                        36
37          Address                                                 City                               State   ZIP code                              37
38                                                                                                                                                   38
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                     XXXXXXXXXXXXXXXXXXXXX              XX      XXXXX-XXXX
39                  (a) Payment 1                (b) Payment 2                (c) Payment 3                (d) Payment 4                             39
40                                                                                                                                                   40
            99,999,999,999.00.00             99,999,999,999.00.00         99,999,999,999.00.00         99,999,999,999.00.00
41                                                                                                                                                   41
42                                                                                                         Total for owner                           42
43                                                                                                                                                   43
                                                                                                       99,999,999,999.00.00
44                                                                                                                                                   44
45          (4) Owner first name     Initial Last name                    SSN                          Owner type (see instructions)                 45
46                                   X                                    999-99-9999– –               XXXXXXXXXXXXX                                 46
47          XXXXXXXXXXXXEntity name          XXXXXXXXXXXXXXXXXXXX                 FEIN                                                               47

48          XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                                   99-9999999–                                                        48
49          Address                                                 City                               State   ZIP code                              49
50                                                                                                                                                   50
            XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX                     XXXXXXXXXXXXXXXXXXXXX              XX      XXXXX-XXXX
51                  (a) Payment 1                (b) Payment 2                (c) Payment 3                (d) Payment 4                             51
52                                                                                                                                                   52
            99,999,999,999.00.00             99,999,999,999.00.00         99,999,999,999.00.00         99,999,999,999.00.00
53                                                                                                                                                   53
54                                                                                                         Total for owner                           54
55                                                                                                                                                   55
                                                                                                       99,999,999,999.00.00
56                                                                                                                                                   56
57          Total payments to transfer to owners. If multiple pages, enter on last page only. These amounts must match estimated payments 1–4 on     57
58          page 1.                                                                                                                                  58
59          (a) Total of payment 1           (b) Total of payment 2       (c) Total of payment 3       (d) Total of payment 4                        59
60                                                                                                                                                   60
            99,999,999,999.00.00             99,999,999,999.00.00         99,999,999,999.00.00         99,999,999,999.00.00
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